A. Abraham

Central Venous Catheter Salvage in Home Parenteral Nutrition Catheter-Related Bloodstream Infections Long-Term Safety and Efficacy Data

BACKGROUND Catheter-related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients. MATERIALS AND METHODS All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used. RESULTS In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase-negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life-threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection). CONCLUSIONS This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.

OC-034 Salvage of central venous catheters in HPN catheter-related blood stream infections is safe and effective: 18 years experience from a national centre

Introduction Catheter-related blood stream infections (CRBSI) are a serious and life-threatening complication in the provision of HPN. European guidelines recommend antibiotic salvage of central venous catheters (CVCs) with CRBSI, wherever possible, to minimise repeated catheter replacement and preserve venous access, but this is based on limited reported evidence.1 Methods Data were analysed from a prospectively-maintained register of all confirmed CRBSIs occurring in patients on HPN since January 1993 to December 2011, managed in a National Intestinal Failure Unit (IFU). Diagnosis of a CRBSI was based on quantitative and qualitative assessment of central and peripheral blood cultures and pour plates. Treatment was commenced according a standardised protocol involving antibiotic and urokinase CVC locks and systemic antibiotic administration. Results A total of 299 CRBSIs occurred in 138 patients (66 single CRBSI, 72 multiple CRBSI) with 377 patients having no catheter infections. The mean number of catheter days prior to developing an infection was 712 (range 5–6128). This represents an overall rate of infection in all patients of 0.39 per 1000 catheter days. A single microorganism caused 87.9% of infections, most commonly coagulase negative staphylococcus (CNS; 49.5% cases). Overall catheter salvage was achieved in 62.2% (intention to treat) of all patients presenting with CRBSIs (Coagulase negative staphylococcus 70.5% (105/149), MRSA 36.4% (4/11), polymicrobial infections 58.3% (21/36), other Staphylococcus aureus 48.3% (14/29) and miscellaneous 56.8% (42/74)). Line salvage was not attempted in 46 patients because of life-threatening sepsis (n=18), fungal line infection (n=7), mechanical catheter problems (eg, co-existing line fracture; n=18) and tunnel line infection (n=3). The catheter was removed in 37.7% (95/299) of cases. There were five deaths in patients admitted to the IFU for management of the CRBSI. Conclusion This is the largest reported series of catheter salvage in CRBSIs and demonstrates that catheter salvage according to a standardised protocol is a safe and effective strategy to preserve essential venous access in patients dependent on HPN. Competing interests None declared. Reference 1. Pittiruti M, Hamilton H, Biffi R, et al. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis, and therapy of complications). Clin Nutr 2009;28:365–77.

Reversal of intestinal failure-associated liver disease (IFALD): emphasis on its multifactorial nature

Patients with intestinal failure (IF) and home parenteral nutrition commonly develop abnormal liver function tests. The presentations of IF-associated liver disease (IFALD) range from mild cholestasis or steatosis to cirrhosis and decompensated liver disease. We describe the reversal of IFALD in an adult patient with IF secondary to severe Crohns disease and multiple small bowel resections. The patient developed liver dysfunction and pathology consistent with IFALD. Multiple causal factors were implicated, including nutrition-related factors, catheter sepsis and the use of hepatotoxic medications. Multidisciplinary treatment in a tertiary IF referral centre included aggressive sepsis management, discontinuation of hepatotoxic medications and a reduction of parenteral nutrition dependency through optimisation of enteral nutrition via distal enteral tube feeding. Upon this, liver function tests normalised.

Improving quality in a national intestinal failure unit: greater efficiency, improved access and reduced mortality

Problem In 2010, there was a significant waiting list for admission to the intestinal failure unit (IFU) at the Salford Royal National Health Service (NHS) Foundation Trust. There had been a steady increase in the number of new patients referred to the IFU (89 patients 2005; 152 patients 2012) and the number of established patients requiring home parenteral nutrition (HPN) (135 patients 2005; 206 patients 2012) over the last decade. The impact of the resulting long waiting list for these complex patients was that patient deaths occurred in those awaiting admission. Design Continuous improvement methodology using the model for improvement and sequential plan–do–study–act cycles. Setting Salford Royal NHS Foundation Trust IFU; a large NHS teaching hospital in Northwest England. Key measures for improvement The primary outcome measures were inpatient length of stay and time spent on waiting list prior to admission. Strategies for change A continuous improvement programme, supported by a project manager. Results There has been a 21% reduction in average length of stay on the IFU from 55.7 to 44.0 days and a reduction of 72% in the average length of time new patients spent on the waiting list for admission from 65.7 to 18.5 days. These changes were associated with concomitant reduction in 30-day readmission rate from 12.1% to 4.5% and early suggestions of reduced inpatient and waiting list mortality. Conclusions It is possible to improve the efficiency of a large national service for complex patients using quality improvement methodology, resulting in improved access and reduced waiting list mortality.

Endoscopic closure of a refractory gastrocutaneous fistula using a novel over-the-scope Padlock clip following de-epithelialisation of the fistula tract

Persistent gastrocutaneous fistula (GCF) is a difficult to manage complication following gastrostomy tube removal, with leakage resulting in distressing sequelae including cutaneous injury, infection and dehydration. Many such patients are high-risk for invasive surgery and, to date, endoscopic closure techniques, including clipping systems, have limitations. We present the case of a 62-year-old woman with persistently leaking GCF 6 months postgastrostomy tube removal, despite maximal antisecretory therapy and postpyloric feeding, and describe failed attempted endoscopic closure with conventional clips. Treatment options were discussed and informed consent was given for an attempt at endoscopic closure using a novel radial closure device (‘Padlock clip’) combined with surgical de-epithelialisation, with the understanding that this device has never previously been used in this setting. At follow-up 2 weeks postprocedure, the patient was asymptomatic with complete healing of the GCF. This approach has advantages over other endoscopic closure techniques and can be considered as an alternative approach to GCF closure.

OC-039 Improving Quality In A National Intestinal Failure Unit: Greater Efficiency, Improved Access, Reduced Mortality

Introduction In 2010, there was a significant waiting list for admission to the Intestinal Failure Unit (IFU) at Salford, one of two current nationally-accredited centres. There had also been a steady increase in referrals to the IFU (89 patients in 2005; 152 patients in 2012) and the number of established patients requiring home parenteral nutrition (HPN) (135 patients in 2005; 206 patients in 2012). The impact of the long waiting list for these complex patients was that patient deaths occurred in those awaiting admission. Furthermore, the ‘Strategic Framework for IF and HPN Services’ in England had earlier highlighted the need for services to ‘foster equity of access’.1 The SRFT IFU team therefore conducted a rigorous assessment of its processes in order to improve patient flow and access to the IFU. The primary aim was to reduce inpatient length of stay (LOS) by 10%. Methods We employed continuous improvement methodology, utilising the Model for Improvement and running sequential Plan-Do-Study-Act cycles. In addition to the key flow data, such as LOS and referral times, process data were collected, including time to intravenous feeding line insertion, time to radiology studies etc., when looking to streamline specific areas of practice. Data were analysed using statistical process control charts produced using QI Macros (KnowWare International, INC.). Statistically significant shifts were determined ‘a priori’ according to standard operating principals for special cause variation.2 Results Process improvements yielded a 20.8% reduction in average length of stay on the IFU from 55.7 to 44.1 days and a reduction of 70.7% in the average length of time spent on the waiting list for admission from 65.1 to 19.1 days. These changes were associated with concomitant reduction in 30-day readmission rates from 12.1 to 4.5% and early suggestions of reduced waiting list mortality. The number of inpatient deaths did not increase; indeed, there was a sustained increase in the number of complete discharge episodes between inpatient deaths (mean increase from 13 to 44). Conclusion A quality improvement model is an effective means of enhancing the efficiency of a large National centre dealing with complex medical and surgical patients. Improvements in inpatient efficiency can reduce waiting times for admission, thus improving access and reducing waiting list mortality. The improvements in efficiency can be achieved without compromising patient safety. References 1 Strategic Framework for Intestinal Failure and Home Parenteral Nutrition Services for Adults in England 2008 2 Langley, G et al. 2009. The improvement guide: a practical approach to enhancing organizational performance. John Wiley & Sons Disclosure of Interest None Declared.

Osteomyelitis in adult patients on long-term parenteral nutrition: 2745 patient-years of experience in a national referral centre

BACKGROUND & AIMS Osteomyelitis (OM) is a rare complication of catheter related sepsis after central venous catheter (CVC) use. The prevalence, characteristics and diagnosis of OM in patients with intestinal failure (IF) receiving long term parenteral nutrition (PN) through CVCs have not previously been described. METHODS This was a retrospective study from a prospectively maintained database of patients referred to a National IF centre. Age, IF aetiology, past medical history, time on PN, OM site and organism(s) cultured were recorded. Patients were divided into 2 groups: OM occurring in the setting of acute (Type 2) IF (AIF) or chronic (Type 3) IF (CIF). Diagnosis of OM was made clinically and supported by radiological and/or microbial evidence. RESULTS 21 cases of OM occurred in 17 patients (7 male (41%)) between 1994 and 2014. 0 cases were observed between 1994 and 1999, 1 case between 2000 and 2004, 6 cases between 2005 and 2009 and 14 cases between 2010 and 2014. There were 11 cases in 7 patients with CIF managed at the IFU between 1994 and 2014; the latter yielded a period prevalence for OM of 0.9% when compared to the 794 HPN patients managed by the IFU over this period. There were 10 cases of OM in 10 patients with AIF; patients with AIF had spent less time on PN before developing OM, compared to patients with CIF; despite this, the rate of preceding CVC infections was higher in the AIF (5.6/1000 catheter days) than in the CIF (0.3/1000 catheter days) group, as a result of patients with AIF contracting CVC infections prior to specialist referral. Patients with AIF had more severe OM compared to those with CIF, according to the Cierny Mader classification. All patients received at least 6 weeks antimicrobial chemotherapy. 4/10 (40%) AIF cases and 2/11 (18%) CIF cases required surgical intervention. No patient died from OM or its treatment. CONCLUSION OM is a rare complication of IF and its treatment, but is being diagnosed more frequently than before and should be noted as a potential focus of sepsis in patients with IF, because it may lead to considerable morbidity.

Su1306 Central Venous Catheter Salvage in HPN Catheter-Related Blood Stream Infections Safety and Efficacy Data From a National Centre

Background/aim: Nonalcoholic fatty liver disease (NAFLD) is considered to be the most common liver disorder in western countries, with a rising prevalence. NAFLD is strongly associated with the presence and severity of obesity, but there is to date no convincing medical therapy. Thus, weight reduction is still the first-line therapy for NAFLD patients. The aim of this study was to evaluate the efficacy of Optifast 52, a commercial interdisciplinary weight loss program, with special emphasis on the adipokines leptin and adiponectin in NAFLD patients. Methods: A total of 72 participants with a BMI of higher than 30 kg/m2 were included. Participants attended weekly over the course of 52 weeks for medical assessment, physical activity, dietary counseling and psychological support. Laboratory values were determined and bioelectrical impedance analyses (BIA) of body composition performed at baseline, and after 26 and 49 weeks. Assessment of NAFLD was carried out using noninvasive parameters: the NAFLD fibrosis score and the BARD score. Results: Of the 72 participants, 42 completed the Optifast program. Initial weight was reduced significantly from 121.1(± 24)kg to 96.3(± 21.9)kg (p=0.0005). Thus, BMI fell from 41.3(± 6.9)kg/m2 to 32.8(± 6.5)kg/m2 and fat mass was reduced from an initial 54.5(± 13.3)kg to 35(± 13.2)kg. The AST/ALT ratio improved with weight loss from 1.17(± 0.5) to 0.83(± 0.26). At baseline, 69% of patients were found to have a pathological AST/ALT ratio, compared to only 24.1% at week 49. The NAFLD score improved from -0.11(± 1.3) to -1.1(± 1.3) on study completion, where a score of -1,455 indicates that liver fibrosis can be excluded. Thus, at the beginning of the study, 14.3% of participants were at low risk of fibrosis, while 28.6% were at high risk. This changed to 39.3% and 3.6% at week 49, respectively. The BARD score improved significantly from 3.5(± 0.87) (baseline) to 2.6(± 1.1) (week 49), coincidentally with an improvement of the leptin/adiponectin ratio from initial 1.16(±0.96) to 0.31(±0.25) (p=0.0005). Conclusion: These data clearly demonstrate the Optifast 52 interdisciplinary weight reduction program to effectively reduce not only liver parameters, but also scores for estimating NAFLD in obese patients. There is evidence in these data that especially the combination of weight reduction through diet and activity has a positive impact on the leptin/adiponectin ratio. As long as no medication is available for this purpose, weight reduction in the form of an interdisciplinary weight management program is therefore a suitable therapy for NAFLD.

Examining the pathophysiology of short bowel syndrome and glucagon-like peptide 2 analogue suitability in chronic intestinal failure: experience from a national intestinal failure unit

IntroductionShort bowel syndrome (SBS) is a leading cause of intestinal failure (IF). Home parenteral nutrition (HPN) remains the standard treatment, with small intestinal transplantation reserved for cases with severe complications to HPN. There have recently been significant developments in growth factor therapy. We aimed to develop a greater contemporary understanding of our SBS-IF subset.MethodWe performed a retrospective observational study of a prospectively maintained HPN audit database in October 2017. Intestinal anatomical details and parenteral requirements were recorded. Each case was assessed for eligibility for growth factor therapy using recently published trials.ResultsOf 273 patients receiving HPN, 152 (55.7%) had type three IF as a result of SBS (SBS-IF), with a mean duration of HPN of 61 months (range 4–416). Mean length of small intestine was 98 cm. Furthermore, 114 (41.8%) patients had an end jejunostomy (SBS-J), 18 (6.6%) had an end ileostomy, and 7.3% of patients had all or part of the colon-in-continuity. Crohn’s disease was the most common underlying pathology. Univariate analysis for the whole HPN cohort demonstrated SBS-IF and a longer duration of HPN to be associated with higher PN energy requirements, p ≤ 0.0001. Of all, 73 (48%) patients with SBS-IF were deemed suitable for GLP-2 analogue therapy, with co-morbidity being the most frequent cause of non-suitability (29.1%).ConclusionWe describe a large U.K. HPN cohort using ESPEN pathophysiological and clinical severity classification. The majority of patients with SBS-IF had a jejunostomy and relatively few had colon-in-continuity. Co-morbidity is the most common contra-indication to GLP-2 analogue therapy.Clinical relevancyGLP-2 analogues are emerging as an important treatment for patients with short bowel syndrome. Our study explores patient suitability in a large HPN cohort managed in a national IF centre. Furthermore, the international variation in the pathophysiology of SBS-IF varies significantly, which can have a bearing on PN requirements and outcomes when GLP-2 analogues are used.

Reversal of intestinal failure associated liver disease fibrosis in a patient receiving long term home parenteral nutrition

Intestinal failure associated liver disease (IFALD) is frequent problem encountered when managing patients receiving parenteral nutrition (PN). Its occurrence is often multifactorial and modification of these factors is vital for the management of such hepatic dysfunction. The use of novel lipid preparations can form part of this management strategy. We present a case whereby such modification of contributing factors, including lipid preparations, led to improvements in IFALD and reversal of hepatic fibrosis.